WRITE the correct answers and the importance of each in a paper
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Submitted Feb 24 at 9:41pm
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Question 1
0 / 1 pts
Which of the following is an expected finding for a chest tube located in the sixth lateral intercostal space?
You Answered
Over time the volume of drainage decreases and the color changes from serous to sanguineous.
There is no drainage; only air escapes the pleural space.
Over time the volume of drainage increases and the color remains sanguineous.
Correct Answer
Over time the volume of drainage decreases and the color changes from sanguineous to serous.
A hemothorax that is resolving properly will have a decrease in the volume of drainage and a color change of drainage from sanguineous (red) to serous. A hemothorax with complications will have steady or increased volume without fluid color change. A pneumothorax (with the usual chest tube location of the second or third intercostal space) will resolve as air is expelled from the pleural space.
Question 2
0 / 1 pts
The nurse is caring for a patient who has a chest tube for a hemothorax. The nurse notices that when the patient coughs, there is a gush of blood in the drainage system. What action should the nurse take?
Correct Answer
Document the normal findings and continue to monitor.
Clamp the chest tube because there has been a pressure change.
You Answered
Notify the health care provider immediately.
Add more water to the suction control chamber to increase suction.
When the patient coughs, it is normal to see a gush of blood; if there is continuous bleeding, it should be reported. In neither case should more water be added to the suction control chamber to increase suction. The only time a chest tube may be clamped is when checking for an air leak in the system or briefly to change or empty the drainage system.
Question 3
1 / 1 pts
The nurse is caring for a patient with a chest tube. Which of the following findings would require follow-up with the health care provider?
Absence of tidaling with a mediastinal chest tube for 24 hours.
The waterless chest tube drainage system was accidentally tipped over.
Gentle fluctuations are noted in the diagnostic indicator of the waterless drainage system.
Correct!
Absence of tidaling for 24 hours with an apical chest tube.
A halt in bubbling for 24 hours and a decrease in drainage to less than 100 to 150 mL per day are good indicators that the patient’s lung has reexpanded. Tidaling is absent with a mediastinal chest tube because its function is to prevent blood from accumulating around the heart rather than to reexpand a collapsed lung. Accidentally tipping over a waterless system can occur without compromising the patient’s condition. The nurse should simply upright the system. The lung is reexpanding normally when a gentle tidaling is present in the diagnostic air-leak indicator.
Question 4
0 / 1 pts
A patient has a pleural effusion caused by a malignancy in her left lung. After a needle aspiration, she experienced a 40% collapse of her left lower lung. She had a chest tube inserted to remove the excess fluid and air that collected in her pleural space. The patient has a waterless drainage system with a diagnostic indicator, which is attached to suction. How will the nurse best determine if the patient developed an air leak?
Correct Answer
The nurse observes bubbling in the diagnostic indicator chamber.
By periodically lifting and draining the tube to the collection device.
The nurse notices the suction float ball fails to remain at the prescribed setting.
You Answered
By clamping the tube and assessing the patient for signs of respiratory distress.
Bubbling in the diagnostic indicator chamber indicates the presence of an air leak in a waterless chest tube drainage system, which must be identified and treated. Periodically lifting and draining the tube to the collection device is done to promote pleural drainage when a dependent loop of tubing is unavoidable. Clamping the chest tube before removal to assess patient’s tolerance is no longer recommended because there is no benefit to the practice. The suction source is set too low when the suction float ball fails to remain at the prescribed setting. Increase the suction until the float ball remains at the correct setting.
Question 5
0.25 / 1 pts
A patient has a mediastinal chest tube inserted following surgery. Which of the following indicates a tension pneumothorax may be developing in the patient? (Select all that apply.)
You Answered
Tidaling in the water-seal chamber.
Correct Answer
Hypotension.
You Answered
Change in color of drainage.
Correct!
Shift of trachea to unaffected side of chest.
Correct!
Tachycardia.
Correct!
Decreased cardiac output.
Question 6
0.33 / 1 pts
Which of the following can cause a tension pneumothorax? (Select all that apply.)
Correct!
Kinking of the chest tube.
Accidentally tipping the waterless drainage system over.
Correct Answer
Clamping of chest tube.
Correct!
Obstruction by a blood clot.
You Answered
Having the suction source set too high.
Question 7
1 / 1 pts
An 18-year-old man presents with shortness of breath and chest pain, which he says has gotten progressively worse since yesterday. He is diagnosed with a spontaneous pneumothorax. The patient will have a chest tube inserted that will be connected to a disposable three-chambered closed chest drainage system with suction. The patient’s preprocedure vital signs are: temperature 99° F orally, pulse 77, respiration 30 with diminished breath sounds on the right, blood pressure 120/80, and SaO2 85%. Which findings support the diagnosis of spontaneous pneumothorax? (Select all that apply.)
Correct!
Respiration.
Pulse.
Blood pressure.
Temperature.
Correct!
Lung sounds.
Correct!
Oxygen saturation.
The temperature, pulse, and blood pressure are within the normal range for a man of his age. The respiratory rate is above normal, and there are abnormal lung sounds. The oxygen saturation is below normal, supporting the diagnosis of a spontaneous pneumothorax. In an 18 year old, vital signs should return to normal once the tube is in place.
Question 8
0.25 / 1 pts
The NAP has asked how to be of assistance during insertion of a chest tube. What activities can a NAP assist with related to insertion, maintenance, and removal of a chest tube? (Select all that apply.)
Resolve problems with the chest tube.
Correct Answer
Report that the chest tube is kinked.
Correct!
Positioning of the patient to facilitate drainage.
Correct!
Gather personal protective equipment for the procedures.
Explain the procedure to the patient.
Correct Answer
Report patient complaints of discomfort or pain.
You Answered
Provide assistance to the health care provider during the procedure.
Question 9
0.5 / 1 pts
The nurse is assisting the health care provider to insert a chest tube. Which of the following actions, if performed by the nurse, would require correction? (Select all that apply.)
The nurse marks the drainage chamber with the start date and time, the beginning amount of drainage, and the nurse’s initials.
Using sterile technique, the nurse holds the drainage tube while the health care provider connects the chest tube.
The nurse tapes the connection between the chest tube and the drainage tube with a spiral pattern.
Correct!
The nurse hands the nonsterile anesthetic vial to the health care provider when ready.
Correct Answer
The nurse coils the tubing on the patient’s bed.
Question 10
1 / 1 pts
Which of the following would indicate the patient with a chest tube connected to suction is ready to have the chest tube removed?
There is presence of a mediastinal shift.
There is hyperresonance upon percussion.
The drainage has changed from sanguineous (red) to serous.
After 2 hours, tidaling has ceased.
There are 500 mL of drainage in 24 hours.
Correct!
After 3 days, tidaling has ceased for 24 hours.
Indications that the patient may be ready to have the chest tube removed include absence of tidaling for 24 hours and less than 100 to 1550 mL of drainage in 24 hours. Cessation of tidaling after 2 hours may indicate that the suction has been shut off or the tube is obstructed. Five hundred milliliters in 24 hours is the expected amount of drainage in an adult with a mediastinal chest tube. The expected drainage in an adult with a pleural tube is 500 to 1000 mL in 24 hours. A change in fluid color does not indicate that the patient is ready to have the chest tube removed, although it is an expected change with time. A mediastinal shift is an indication of a tension pneumothorax. Although resonance on percussion may indicate that the lung is reinflated, hyperresonance is an indication of a potential tension pneumothorax.
Question 11
1 / 1 pts
The patient is anxious about having his chest tube removed. He states, “I’m afraid my lung will just collapse again. Is there anything I can do to help? What is the nurse’s best response?
“There’s nothing you can do to keep that from occurring, so you might as well relax. I’m sure you’ll be just fine.”
“Yes, you can lie very still and focus on taking normal breaths while the health care provider removes the chest tube.”
Correct!
“Yes, you should exhale completely and bear down while the chest tube is being removed. We will tell you when.”
“There is no reason to worry. That rarely happens, and if it does the doctor will just insert a new chest tube.”
Having the patient exhale completely and perform the Valsalva maneuver will prevent air from being sucked into the chest as the tube is removed. A complication associated with removal of chest tubes is recurrent pneumothorax, which results from atmospheric air reentering the pleural cavity. This occurs when the patient inhales during tube removal. If a recurrent pneumothorax occurs, the health care provider may insert another chest tube. However, this is not the best response because it fails to comfort the patient and fails to instruct the patient regarding appropriate action. Telling the patient there is nothing he can do and saying he’ll just be fine are both inaccurate and offer only false reassurance.
Question 12
1 / 1 pts
A patient with a hemothorax and hemoglobin of 8 mg/dL is to have an autotransfusion of chest tube drainage. Which of the following would be a contraindication?
An autotransfusion system (ATS) bag used for collection of chest tube drainage.
Correct!
Collected blood in the chest drain for 8 hours.
Chest tube drainage collecting at a rate of 100 mL/hr.
A low hemoglobin level.
Collected blood never remains in the chest drain or ATS blood bag for more than 6 hours before autotransfusion. A low hemoglobin level is an indication for need of a blood transfusion or autotransfusion of chest tube drainage. Blood loss of 50 to 100 mL/hr through a chest tube indicates active bleeding and is an indication for reinfusion of chest tube drainage. An ATS bag should be used for collection of chest tube drainage because it contains a filter to remove extraneous materials and microemboli.
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